Parents' perspectives on the role of kin in child-rearing: a qualitative study on Greenland's universal parenting programme MANU.

Nurturing care and protection from parents and community in the early years of life are fundamental for a child's development. The article aims to explore what relations parents see as meaningful in their child's upbringing and how these are shaped, and how these perspectives are reflected in MANU. MANU is a universal parenting programme in Greenland. Ten of 40 interviews with parents were selected for the analysis of this article's objective. Five grandparents were interviewed. Grandparents are the child's closest extended family members and provide support to parents. Parents placed between one to 19 extended family members in their child's network. Eating and being in nature together, along with familial and intergenerational connectedness, were deemed valuable and important aspects in child-rearing. Parents' own experiences in childhood can influence and complicate how parents place their new family within the extended family. The MANU materials address aspects in the role of kin that parents and grandparents described in interviews. The format and delivery of MANU aims to be universal and mostly addresses Western epistemologies, but both Western and Inuit epistemologies coexists in Greenland. This article creates a window into the existing context parents navigate in. It is important that initiatives are built within this context to ensure they are relevant to families.

Parents' perspectives on preparing for parenthood: a qualitative study on Greenland's universal parenting programme MANU 0-1 year.

BACKGROUND: The transition to parenthood has received increasing attention in research, partly due to evidence pointing out the crucial developmental period of a child's first thousand days. Parenting programmes aim to prepare and support families in their transition and distress. For a programme to be implemented successfully it is important to consider parents' needs and resources. Bringing parents' perspectives and experiences to the forefront of the implementation of the Greenlandic parenting programme MANU 0-1 Year (MANU) is important for determining if the programme can meet its aim of contributing to thriving families. This study aims to investigate how parents' notions and experiences of parenthood are reflected and challenged in MANU. METHOD: Data were collected in three of Greenland's five municipalities. Qualitative interviews were held with 38 mothers and 12 fathers either individually or as couples: a total of 40 interviews. Additionally, a Sharing Circle with three fathers was held. Interviews were in Greenlandic or Danish. A thematic, inductive analysis was applied. RESULTS: In their transition to parenthood, participants experienced a reprioritisation of their life and changes in their network. It is important to parents that their child experiences security and care, and participants describe this in contrast to their own childhood. Community is the most important value in child-rearing. Conversations and advice from family members and friends are mentioned as a means to prepare for birth and parenthood. Additionally, conversations with midwives and MANU sessions were also used for preparation. Parents appreciated learning from and listening to other parents in MANU sessions. However, accessing MANU depends on the individual parent's interest and ability to attend sessions. CONCLUSIONS: Parents' notions and experiences of parenthood are addressed in the programme, but the use of MANU depends on the parents' attendance and how it is organised and locally offered. The study suggests that MANU has the possibility to create a space for parents to reflect and prepare. However, for MANU to be universal as intended and to reach both mother and father the facilitation of sessions could be revisited.

An in-depth implementation study of the Greenlandic parenting program MANU's initial stages of implementation.

In Greenland, the universal parenting programme MANU was developed in 2016. After documenting the initial years of MANU's implementation, this study aimed to identify implementation determinants focusing on i) which context MANU was conceptualised in and how it was developed and ii) how MANU was implemented and initially received in the healthcare system. A qualitative in-depth implementation study was conducted: document analysis, 38 interviews, one focus group discussion, and observations at two trainings for professionals and four parent sessions. Participants included stakeholders from both the health and social sector and from management to practitioner level. MANU was conceptualised based on a political desire to ensure children's well-being by providing parents with the essential parenting skills, and a desire to create a programme for the Greenlandic context. Professionals welcomed the MANU materials, but anticipated or experienced barriers in implementing MANU. The first years of MANU focused on disseminating material and training professionals. Despite political support and financial security enabling implementation, an assessment of the implementation capacity from the very beginning could have prevented some of the implementation challenges identified. Insights on parents' perspectives and local implementation are lacking and need to be brought to the forefront of the implementation process.

Patient experience studies in the circumpolar region: a scoping review.

OBJECTIVES: Patient experiences with health systems constitute a crucial pillar of quality care. Across the Arctic, patients' interactions with the healthcare system are influenced by challenges of access, historical inequities and social determinants. This scoping review sought to describe the range and nature of peer-reviewed literature on patient experience studies conducted within the circumpolar region. DESIGN: In a partnership between Danish/Greenlandic, Canadian and American research teams, a scoping review of published research exploring patient experiences in circumpolar regions was undertaken. DATA SOURCES: Seven electronic databases were queried: MEDLINE, Embase, Scopus, 'Global Health 1910 to 2019 Week 11', CINAHL, PsycINFO and SveMed+. ELIGIBILITY CRITERIA: Articles were eligible for inclusion if they (a) took place in the circumpolar region, (b) reported patients' perspective and (c) were focussed primarily on patient experiences with care, rather than satisfaction with treatment outcome. DATA EXTRACTION AND SYNTHESIS: Title and abstract screening, full-text review and data extraction was conducted by four researchers. Bibliometric information such as publication date and country of origin was extracted, as was information regarding study design and whether or not the article contained results relevant to the themes of Indigenous values, rural and remote context, telehealth and climate change. Two researchers then synthesised and characterised results relevant to these themes. RESULTS: Of the 2824 articles initially found through systematic searches in seven databases, 96 articles were included for data extraction. Findings from the review included unique features related to Indigenous values, rural and remote health, telehealth and climate change. CONCLUSIONS: The review findings provide an overview of patient experiences measures used in circumpolar nations. These findings can be used to inform health system improvement based on patient needs in the circumpolar context, as well as in other regions that share common features. This work can be further contextualized through Indigenous methodologies such as sharing circles and community based participatory methods.

"We come as friends": approaches to social accountability by health committees in Northern Malawi.

BACKGROUND: In Malawi, as in many low-and middle-income countries, health facility committees (HFCs) are involved in the governance of health services. Little is known about the approaches they use and the challenges they face. This study explores how HFCs monitor the quality of health services and how they demand accountability of health workers for their performance. METHODS: Documentary analysis and key informant interviews (7) were complemented by interviews with purposefully selected HFC members (22) and health workers (40) regarding their experiences with HFCs. Data analysis was guided by a coding scheme informed by social accountability concepts complemented by inductive analysis to identify participants' perceptions and meanings of processes of social accountability facilitated by HFCs. RESULTS: The results suggest that HFCs address poor health worker performance (such as absenteeism, poor treatments and informal payments), and report severe misconduct to health authorities. The informal and constructive approach that most HFCs use is shaped by formal definitions and common expectations of the role of HFCs in service delivery as well as resource constraints. The primary function of social accountability through HFCs appears to be co-production: the management of social relations around the health facility and the promotion of a minimum level of access and quality of services. CONCLUSIONS: Policymakers and HFC support programs should take into account the broad task description of HFCs and integrate social accountability approaches in existing quality of care programs. The study also underscores the need to clarify accountability arrangements and linkages with upward accountability approaches in the system.

Symposium on "parental education" at the ICCH17.

This symposium report provides a brief overview of the six programmes and studies on parental education and maternal health services within the circumpolar region presented in the symposium "parental education" at the 17th International Congress of Circumpolar Health in Copenhagen, Denmark, August 2018.

Determinants of an integrated public health approach: the implementation process of Greenland's second public health program.

BACKGROUND: Greenland struggles with a high prevalence of smoking, alcohol and drug abuse. In response to the increasing need for preventive initiatives, the first public health program Inuuneritta was introduced in 2007. Internationally, frameworks focus primarily on the implementation of a single, well-described intervention or program. However, with the increasing need and emergence of more holistic, integrated approaches, a need for research investigating the process of policy implementation from launch to action arises. This paper aims to augment the empirical evidence on the implementation of integrated health promotion programs within a governmental setting using the case of Inuuneritta II. In this study, the constraining and enabling determinants of the implementation processes within and across levels and sectors were examined. METHODS: Qualitative methods with a transdisciplinary approach were applied. Data collection consisted of six phases with different qualitative methods applied to gain a comprehensive overview and understanding of Inuuneritta II's implementation process. These methods included: observations and focus group discussions at the community health worker (CHW) conference, telephone interviews, document analysis, and a workshop on results dissemination. RESULTS: Enabling determinants influencing the implementation process of Inuuneritta II positively were high motivation among adopters, local prevention committees supporting community health workers, and the initiation of the central prevention committee. In contrast, constraining determinants were ambiguous program aims, high turnovers, siloed budgets and work environments, and an inconsistent and neglected central prevention committee. CONCLUSION: Inuuneritta II provided a substantial framework for an integrated health policy approach. However, having a holistic and comprehensive program enabling an integrated approach is not sufficient. Inuuneritta II's integrated approach does not harmonise with the government's inflexible organisational structure resulting in insufficient implementation.

Informal social accountability in maternal health service delivery: A study in Northern Malawi.

Despite the expansion of literature on social accountability in low-and middle-income countries, little is known about how health providers experience daily social pressure and citizen feedback. This study used a narrative inquiry approach to explore the function of daily social accountability relations among maternal health care workers in rural Malawi. Through semi-structured interviews with 32 nurses and 19 clinicians, we collected 155 feedback cases allowing the identification of four main strategies social actors use to express their opinion and concerns about maternal health services. We found that women who used delivery care express their appreciation for successful deliveries directly to the health worker but complaints, such as on absenteeism and poor interpersonal behaviour, follow an indirect route via intermediaries such as the health workers' spouse, co-workers or the health committee who forward some cases of misbehaviour to district authorities. The findings suggest that citizen feedback is important for the socialization, motivation and retention of maternal healthcare workers in under resourced rural settings. Practitioners and external development programmes should understand and recognize the value of already existing accountability mechanisms and foster social accountability approaches that allow communities as well as health workers to challenge the systemic obstacles to quality and respectful service delivery.